Most primary care visits don't need to be seen in the office

by Emily P. Walker

If a Martian visited Earth and wandered into a primary care physician’s office, he’d marvel at how inefficiently the average doctor spends his or her time.

The Martian might wonder why the primary care doctors sees 20 or 30 patients a day when many of the consultations could be done over the phone, which would make things easier for both doctor and patients.

At least, that’s what Larry Casalino, MD, PhD, chief of the Division of Outcomes and Effectiveness Research at Weill Cornell Medical College in New York City, thinks a Martian would notice.

Because that’s what struck him as young doctor just starting out.

He marveled at the amount of time he spent doing nonmedical tasks, the unnecessarily frantic pace, and how, at the end of every day, he felt he had just narrowly avoided the Apocalypse.

Casalino laid out what he envisions as a better workday for a primary care doctor in an article in the May issue of Health Affairs — a theme issue entitled Reinventing Primary Care.

Casalino, who practiced as a family physician for 20 years in Half Moon, Calif., sat down with MedPage Today’s Emily Walker during a break in a briefing at the National Press Club to discuss how a total redesign, shift in thinking, and restructuring of payments could reap benefits for primary care physicians and their patients.

Emily P. Walker is a MedPage Today Washington Correspondent.

Originally published in MedPage Today. Visit MedPageToday.com for more primary care news.

Comments

KP Internist
Medical home model doesn’t work if the pay system is still fee-for-service. NCAL KP is really a medical home model. Our model is mostly pre-payment, so our incentive is to always find the most efficient way to manage our patient’s needs. Whether that is through office visits, secure messaging, group visits or telephone, I get paid the same. There are incentive payments for hitting quality numbers for access or performance, but this nominal relative to the salary. Patients are “touched” by many physician extenders in our system to work towards this same goal. This is especially true for treating patients with chronic diseases. It allows me to focus on urgent or complicated matters and avoid the monthly wellness visits that prevents access for my urgent appointment requests. I don’t think that you can have a medical home model will work unless you can change the payment system to something similar to KP.
http://nostrums.blogspot.com Doc D
I ran a hospital in the 90′s where we tried this, along with other hospitals in the network. It allowed us to give first aid, home care, and refill guidance without taking up patient and doctor time. Providers were salaried, but had an empanelled population.
After the second lawsuit in the network for failure to diagnose it was cancelled, despite the fact that we set it up specifically to assist patients but limit liability exposure. All contact that wasn’t face-to-face contained a disclaimer, was limited to common sense guidance, and included an offer of an appointment (a specific one, not just “call the appt line”).
We couldn’t overcome the perceptions and expectations (people hear what they want to hear), or the litigation opportunity it offered.
rezmed09
Sounds simple, doesn’t it? where is the evidence? What are the appropriate intervals to see patients for a given set of chronic diseases and refills? It is a matter of time before this gets fleshed out – along with the payment issues. But it really seems like we are losing the best part of medicine – human interaction. Call me old-fashioned, but phone calls and emails and refills doesn’t seem safe to me.
stargirl65
I could provide better care to patients if my time spent on email communications and phone communications was properly compensated. As it is now, I can only get paid for face-to-face interactions. Ironically it is most likely costing the companies MORE money to not cover those other services. There are many things that could be handled by a 5 minute phone/internet interaction for a smaller fee. The patient might not even have to leave work, thereby increasing productivity for our country.
I would love to do other patient interactions, but if I provided them for free all day long then I would go broke. I have overhead to make.
Finn
I have access to a secure email system to communicate with my internist, but I use it only to ask simple questions (such as “Can I stop drug x for two weeks and see how I feel?”) or give her quick updates about my visits to specialists, knowing she’ll get the full report later from them. Otherwise, I’ll make an appointment to see her even when I know she doesn’t need to examine me or see me in person to handle my issue because I know that she won’t be paid for the 5-minute phone call it would take.
The entire medical payment system is designed to create gross inefficiencies, massive overhead, jammed waiting rooms, excessive delays in getting to see a physician, and ridiculous work hours for primary care physicians–and the health care reform bill does nothing to change that.
Max
Pay me $25/email and $25/phone call and I’ll be on the computer with a phone on my desk 24/7. I’ll even be there in the middle of the night playing the Sims waiting for an email and phone call. Pay me. Bottom line. Pay. Me. We had a study that paid the cab driver $50 to pick up the patient to bring them in for a visit. I said pay me $50 I’ll go get them myself. I’ll throw in the return trip for nothing.
family practitioner
Be careful of what you wish for.
If we start getting reimbursed for care over the phone, we will just be outsourced to another continent.
KP Internist
The point of physician extenders is to improve access for patients. Do I really need to be involved with a routine BP check? Can’t I just have them get a BP check at a walk-in station and then I can send them a message later to have their medications adjusted. Do, I have to make a patient book an appointment and pay a copayment for that? Now that I not busy doing that type of work, I can see my patients for urgent visits or spend more time with them to discuss wellness. If the physician shouldn’t be involved with a type of work, then they shouldn’t have to be. There are more important things for us to do. The point however, is not to replace the doctor-patient relationship. It is just meant to make us more efficient. I can titrate insulin a whole lot faster if patients can just send me their readings weekly. Heck, why don’t I just give them a flowchart that gives them specific instructions on how much to increase their bedtime NPH by based on their weekly readings.
MB
“Patients are “touched” by many physician extenders in our system to work towards this same goal.”
Just a system where the doctor-patient relationship takes a back seat. I don’t what to be passed around the office. I want a provider who cares for my needs-both urgent and chronic. I left the TransforMed clinic because of this issue. I am willing to pay for this so please don’t accuse me of being cheap.
MB
“Can’t I just have them get a BP check at a walk-in station”
Physician extenders is a phrase used to describe a physicians assistant or a perhaps a nurse practitioner, not someone in a lab or a medical assistant. The patient didn’t really see a provider, only someone to gather information.
Does it really matter if you see the doctor for urgent things and the physician assistant for chronic problems and check up or visa versa? Doesn’t that make me just a chart to everyone at the clinic, where no one actually sees the progression of disease, only the write up. What did you miss because you didn’t actually see the patient?
Primary Care Internist
I think people who are salaried by university hospitals shouldn’t give their opinions on how actual practicing primary care docs are paid.
Or perhaps all of us should aspire to become chiefs of some nebulous department, like the “department of outcomes and effectiveness research”. That’s like the specialty “interventional lipidology”.
cdahlin
I don’t know of many of my patients that could be managed that way-I have many 90 year olds, and frequently what the patient thinks is the matter has nothing to do with the exam. I think there is no substitute for eyeballing a patient. Yourself.
http://thehappyhospitalist.blogspot.com Happy Hospitalist
most hospitalized patients don’t need to be seen either.
DJ
Relying only on using more phone and email is not the answer. Instead, better options would be : increase number of providers, create better triage to limit unnecessary visits, pass tort reform to get a handle on liability issues (which create many unnecessary visits due to defensive medicine,) and educate society (mandatory health courses in school about the SCIENCE of their bodies and how the medical system works and what it’s limitations are.)
A good part of my time is spent dealing with medically illiterate/unsophisticated people who don’t understand the first thing about the science of their bodies or medical science. This is big problem because they panic easily, and they have demands which are unrealistic.
AnnR
My sister is tending to an aging relative who has coverage in a plan with a full-fledged email system and many “extenders”. She likes the set-up. She’s got MPOA and uses the online system to communicate with various people and manage prescriptions. It’s a big production to get the relative to the doctor so anything that lets her bypass visits for simple things is a plus for her.
She likes that she can send the doctor messages before office visits and outline problems. Usually he gets those before he walks into the room and this helps the visit be productive without getting the older relative getting all up in arms by reeling off her problems.
Our father has a similar condition but has fee-for-service and my mother to ferry him about to appointments, and he does get more care. I don’t know that one of them is doing better than the other because of their care. My sister doesn’t have the luxury of making doctor visits for our relative her main activity so the support of extenders and an EMR seems like a helpful compromise.

Most primary care visits don’t need to be seen in the office

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